GW1--04832_Well Construction - GW1_20230728

WELL CONSTRUCTION RECORD
Ibis form can be used for single or multiple wells For internal Use ONLY:
1.Well Contractor Information: i
Rex Meadows 14.WATER ZONES {
FROM TOft. DESCRIPTION I
Well Contractor Name R.
2113-A ft. ft.
I
NC Well Contractor Certification Number IS.OUTER CASING(for mold-eased wells)OR LINER(if ap Doable)Clearwater Well Drilling Inc. FROMit. ITO ft. °�METERin ITHICKNFSS 1 MATERIAL
Company Name /� 16.INNER CASING OR TUBiNG{geothermal dosed-loop)
I- D I�1�k J FROM TO DIAMETER g fi[CIQdESS MATERIAL
2.Well Construction Permit#: v 1 N u(/� ft. tL
List all applicable well construction permits(i.e.County,State.Variance.etc.)
ft. ' ft. la
3.Well Use(check well use):
17.SCREEN f.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THiCKNESS MATERIAL
❑Agricultural ❑ltfunicipal/Public ft. f4 in. I
lAeothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft. In. I
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.CROUr I
❑hngation FROM TO •
MATERIAI EMPLACEMENT METHOD&AMOUNT J
Non-Water Supply Well: ft. ft.
❑Monitoring ORecovery ft. R.
Injection Well: ft. tt. I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) I
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 1 EMPLACEMENT METHOD
❑ infer Test rt. ft. I
❑Stormwater Drainage
❑Experimental Technolo 0• It.
gy ❑Subsidence Control
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach addldonel sheets H(necessary)
FROM TO DESCRIPTION calm,hardness.Balrm&type.grata size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a ft, a75 R. /ea
4.Date Well(s)Completed: Q`U Well[D# O. y g/vztj.t f�`�� al1. R.
5 ell Locatio
ft. ft. I
Fa(cilility,OwnerrName �) Faci ity Y)M(if applicable) (��J ft. t. I I;
L () ei In IW� Dr- A,e/)\>,,Y,ir111L it.
I .J
P teal Address,City,and Zip V'�
2U.rv )rnb /DQ '�� ��
County ��� LL!`�J 70000 J}I.REMAR[(S 1pfari A,1 Pie.T.ase&i.0 link
Parcel Identification No.(PIN) ✓ ,,,;, , OG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: t�7L'+
(if well field,one lat/long is sufficient) C h 32 /n ertiliC on:
L� --� (p —g a
� ofCethfiedWell on clot Date
the
6.is(are) tvell(s:�ermaneet or ❑Temporary
By signing this form.I hereby eery that the uell(si mu(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200!iWell Constntction Standards and that a
7.Es this a repair to an existing well: ❑Yes or No copy of this record has been provided to the well on r.
if this is a repair,fill out know;well construction information rploin the nature of the
repair under 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
a - 975 F4-, You may use the back of this page to provide additional well site details or well
B.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you Can
submit one Arm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form with a 30 days of completion of well
For multiple wells list all depths;,different(example_3C200'and 2G100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Info tion Processing Unit,
If water level is above casing.use..+•• 1617 Mail Service Center,Rale sending the form to the address in 24a
above,also submit a copy of this form withi%30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Ralei h,NC 27699-1636
13a.Yield(gpm) Method of test: 24e.For Water Supply&Infection Wells: in addition to sending the form to
the address(es)above, also submit one copy f this form within 30 days of
13b.Disinfection type: aunt: completion of well construction to,the coup health department of the county
where constructed.
Form GAY-1 North Carolina Department ofEnvimmnent and Natural Resources-DivisionofWaterQuality
Revised Jan.2013
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